These proposals are highly technical and tough to slog through, so I tried to deal with the big picture.

July 27, 2014

TO: FDA

FROM: Marion Nestle, Professor of Nutrition, Food Studies and Public Health, New York University

RE: Comments: Serving size proposals, Docket No. FDA-2004-N-0258

In addressing the question of how to change serving size designations on food labels, FDA is faced with an impossible dilemma . Serving sizes, which are supposed to be based on amounts typically consumed from packaged products, are invariably perceived as recommendationsfor dietary intake.

To comment on each of the bold-face, italicized points:

Typically consumed: This information derives from dietary intake surveys which invariably underestimate actual intake, often by 30% to 40%.

Packaged foods: Food labels only appear on packaged foods. RACC amounts on packaged foods are often much lower than amounts served in restaurants or fast-food places (pizza is an obvious example). It is unclear whether amounts reported as consumed are from packages (with Nutrition Facts labels) or are from restaurants or fast-food places where portion sizes can be much higher than those for foods in packages.

Recommendation: Substantial anecdotal information suggests that people view labeled serving sizes as what they should be eating. They view the serving sizes as meaningless compared to the portion sizes of foods they are accustomed to eating.

What is well established is that overall calorie intake has increased since RACCs were established in 1993 and marketplace portion sizes have also increased.

Therefore, any increase in RACC runs the risk of being interpreted as a validation of current portion sizes and as a recommendation to eat more.

On the other hand, larger portions have more calories. These must appear on the label.

To address this dilemma, FDA should:

Make dual-column labeling mandatory for all food and beverage packages likely to be consumed in one sitting.

Require total calories in the package to be displayed on the front of the package.

Include a footnote explaining that the serving size is not meant as a recommendation

PIGOTT, J.:
We hold that the New York City Board of Health, in adopting the “Sugary Drinks Portion Cap Rule”, exceeded the scope of its regulatory authority. By choosing among competing policy goals, without any legislative delegation or guidance, the Board engaged in law-making and thus infringed upon the legislative jurisdiction of the City Council of New York.

Although the decision applies to the Portion Cap Rule, it has a much larger meaning.

The ruling means the Court does not accept the idea that health departments have the right to set health policy for city residents. I suspect we will be seeing the implications of this ruling for a long time to come.

Today’s ruling does not change the fact that sugary drink consumption is a key driver of the obesity epidemic, and we will continue to look for ways to stem the twin epidemics of obesity and type 2 diabetes by seeking to limit the pernicious effects of aggressive and predatory marketing of sugary drinks and unhealthy foods.

This doesn’t sound like the city will appeal to the U.S. Supreme Court, but maybe it’s too early to say.

I will post additional comments later, as they come in. Stay tuned.

Additions:

As I just told a reporter, ”

The key issue here is whether health departments have the right to set policy to protect the health of citizens under their jurisdiction. This court says no, but this seems precedent-setting. The medical community most definitely should support measures to improve the environment of food choice. Changing the behavior of individuals is extremely difficult and rarely successful; it works much better to improve the environment so it’s easier for individuals to make healthier choices.

On the court decision: The vote was 4 to 2, with one abstention. Here’s a quotation from Judge Susan Read’s dissenting opinion:

What petitioners have truly asked the courts to do is to strike down an unpopular regulation, not an illegal one…To sum up, if the People of the City or State of New York are uncomfortable with the expansive powers first bestowed by the New York State Legislature on the New York City Board of Health over 150 years ago, they have every right and ability to call on their elected representatives to effect change. This Court, however, does not…The majority fails to advance any persuasive argument why the judiciary should step into the middle of a debate over public health policy and prohibit the Board from implementing a measure designed to reduce chronic health risks associated with sugary beverages just because the Council has not chosen to act in this area.

In a blistering dissent of the opinion, Judge Susan P. Read wrote that the ruling ignored decades of precedent in which the Board of Health was given broad purview to address public health matters, such as regulating the city’s water supply and banning the use of lead paint in homes. The opinion, Judge Read wrote, “misapprehends, mischaracterizes and thereby curtails the powers of the New York City Board of Health to address the public health threats of the early 21st century.” One justice in the majority, Judge Sheila Abdus-Salaam, seemed to share those concerns, writing in a separate concurrence that “no one should read today’s decision too broadly.”

It’s always amusing to hear what the Washington Legal Foundation, which filed an amicus brief supporting the soda industry’s position, has to say:

Jane Delgado of the National Alliance for Hispanic Health’s issued a statement:

We are deeply disappointed that the court today limited the power of the NYC Board of Health to
act on behalf of the health of New Yorkers… The portion cap rule is the right policy for New York City and communities throughout the nation facing the rise of chronic diseases, such as diabetes.

I’m in Washington, DC this week on a bit of book tour for Eat, Drink, Vote (see Appearances for schedule).

At my Politics & Prose bookstore event last night, I got asked why I think the food environment matters so much in dietary choice. Isn’t food choice a matter of personal responsibility?

It is, of course, but the food environment greatly influences personal choice.

Two examples:

Large portions: just about anyone presented with a large portion of food with eat more from it, take in more calories (larger portions have more calories!), and underestimate the calories consumed by a much greater proportion than from a smaller amount.

Salt intake: Because 80% or so of salt in the American diet comes from processed and restaurant foods, people eating in restaurants have no control over the amount of salt they take in.

To make it easier for people to take in fewer calories and less salt requires changes in the food environment: serve smaller portions and reduce the salt in restaurant foods.

I attended the brief appeals hearing yesterday at which lawyers for the New York City Department of Health (DOH) and the American Beverage Association (ABA) presented final arguments for and against the DOH 16-ounce soda cap initiative (for recap, see previous post).

The judges challenged the DOH lawyer on jurisdiction, judicial precedents, scientific basis, efficacy, rationality, and triviality. One said “Do you need a PhD in public health to know that sugary drinks aren’t good for you?”

Another kept referring to the initiative as a ban: “It would mean sodas cannot be sold…”

The big issues raised by ABA:

Does DOH have jurisdiction?

Is the cap rational?

Does the soda cap adequately balance public health, personal liberty, and economic factors (i.e., beverage companies’ “rights” to sell as much sugar water as they can get away with)?

Reporters from the Associated Press and the New York Times must have been there too. Both noted that the judges were much tougher on the DOH attorney than on the one from the ABA. The DOH attorney seemed to have trouble responding to questions about precedents. Did she not read the DOH’s impressive “plenty of precedent” piece?

Judge drinks the Kool-Aid

In putting Mayor Bloomberg’s soda ban on ice, Manhattan Supreme Court Justice Milton Tingling did a huge disservice to the health and welfare of hundreds of thousands of New Yorkers.

Tingling concluded that the prohibition against selling sugared beverages in containers larger than 16 ounces was both arbitrary and beyond the authority of the Board of Health, which approved the regulations.

The only thing arbitrary here was Tingling’s ruling. More, the judge was the only party who was guilty of overreaching.

At heart, he simply substituted his judgment as to sound public policy for the board’s — an action that’s beyond a judge’s proper purview.

Most amazingly, Tingling held that the board had acted rationally in voting the portion cap as one method of trying to rein in the city’s epidemic of obesity and obesity-related diseases.

He bought the indisputable premise that the board was right to draw connections among high soda consumption, obesity and diabetes, which are debilitating New Yorkers young and old.

But then the judge threw that over by stating the obvious fact that the board did not have the power to ban supersized sugar drinks everywhere, only in establishments regulated by the Health Department.

Because the public could get a 32-ounce cup at, say, a 7-Eleven, but not at restaurants, he in effect deemed the ban to be an ill-designed contraption destined to fail. But who is Milton Tingling to say that? No one.

His fundamental error was to consider the regulation from the point of view of vendors who were hoping to get out from under it.

Those covered by the ban claimed they were the victims of capriciously unequal treatment and shifted Tingling’s concern away from the pressing rationale for a regulation that would have been broadly applied.

There’s nothing arbitrary about the consequences of drinking large quantities of sodas and other overly sweetened beverages.

The correlation in certain communities among consuming soda, becoming obese and contracting related diseases are certain.

The neighborhoods with the highest obesity rates — Harlem, the South Bronx, central Brooklyn — have the largest percentages of people who are likely to drink more than one sugar-sweetened beverage each day.

All too predictably, people in low-income areas such as Bedford-Stuyvesant and East New York, Brooklyn — places where soda consumption is highest — are four times as likely to die from diabetes as residents of the more affluent upper East Side, where people generally consume far fewer sugary drinks.

No matter.

Tingling attended to the arguments of businesses looking after their own financial interests over the demands of public health — while at the same time declaring that the Board of Health is barred from taking into account the substantial economic costs generated by obesity.

Ultimately, Tingling bought into the all-or-nothing argument — the same line of thinking that killed an earlier Bloomberg proposal that would have barred people from buying sugary sodas with food stamps.

The U.S. Department of Agriculture killed that experiment, asserting that it would be unfair and unproductive to target only a limited population in such a test. So Bloomberg tried to go bigger, and Tingling shot him down.

If bringing down a serious threat is a rational goal, as Tingling wrote, then you do it as best you can, even incrementally.

A halfway measure is better than no measure and is certainly not arbitrary.

Bloomberg vows an appeal.

Here’s hoping that Tingling’s judicial superiors recognize that pursuing public health is not just rational, it’s imperative.

There are better ways for Mr. Bloomberg to use his time and resources to combat obesity. One is to push Gov. Andrew Cuomo and the State Legislature to impose a penny-per-ounce tax on sugary drinks…the big-drinks ban was ill conceived and poorly constructed from the start.

Late yesterday afternoon, while I was fielding international calls about the soda size cap scheduled to take effect today, state Supreme Court justice Milton A. Tingling “enjoined and permanently restrained” New York City from implementing the portion-size rule.

Does not find the necessity to address at this point the appropriateness of the Board’s attempts to classify obesity as an epidemic or a contributing factor to chronic disease…the issue before this court is whether the Board has the authority to mandate which issues come under its jurisdiction…in this case it the Portion Cap Rule and whether the Board has the authority to promulgate same (page 10).

He concludes that the proposed rule is:

Fraught with arbitrary and capricious consequences… uneven enforcement even within a particular City block, much less the City as a whole…It is arbitrary and capricious because it applies to some but not all food establishments in the City, it excludes other beverages that have significantly higher concentrations of sugar sweeteners and/or calories on suspect grounds, and …no limitations on re-fills…the Portion Cap Rule is found to be arbitrary and capricious (page 34).

And this:

The Portion Cap Rule, if upheld, would create an administrative Leviathan…The Rule would not only violate the separation of powers doctrine, it would eviscerate it. Such an evisceration has the potential to be more troubling than sugar sweetened beverages (page 35).

the ire of the American soft-drink industry, which undertook a multimillion-dollar campaign to block it, flying banners from airplanes over Coney Island, plastering subway stations with advertisements and filing the lawsuit that led to the ruling.

The court ruling provides a sigh of relief to New Yorkers and thousands of small businesses in New York City that would have been harmed by this arbitrary and unpopular ban. With this ruling behind us, we look forward to collaborating with city leaders on solutions that will have a meaningful and lasting impact on the people of New York City.

Liberty from big soda: Why Bloomberg’s ‘ban’ should be only the beginning of a public health revolution

Barring any late legal surprises, Mayor Bloomberg’s 16-ounce cap on sugary sodas goes into effect on Tuesday, March 12. After that, restaurants, movie theaters, sports venues and food carts will not be permitted to sell extra-large portions of sugar-packed drinks.

Stay calm. This does not signal the end of democracy in America. This is not the nanny state gone out of control.

If we want Americans to be healthy, we are going to have to take actions like this – and many more – and do so soon. It’s long past time to tax sugar soda, crack down further on what gets sold in our schools, tackle abusive marketing practices, demand a redesign of labels – and extend the soda cap, no matter how controversial it may seem. This must be the beginning, not the end, of efforts toward a healthier America.

In short, we need a series of serious changes to make the healthy choice the easy choice. The soda size cap is a nudge in that direction. You will still be able to drink all the soda, and down all the sugar, that you want. The cap on soda size makes it just a tiny bit harder for you to do so.

That “tiny bit harder” is its point. If you have to order two sodas instead of one, maybe you won’t. If you have to add sugar to your coffee drink yourself, maybe you will only add one or two teaspoons instead of the 10 or more someone else put in there for you.

For a public health nutritionist like me, the soda size cap is a terrific idea. Unlike other foods, sodas are a unique target for intervention. They contain sugars – and sugar calories – but nothing else of nutritional value. They are candy in liquid form. Candy has a place in healthy diets, but a small one. So it should be for sodas.

It’s no surprise that people who drink large amounts of liquid candy have worse diets, are heavier, and have more health problems than those who do not. And it looks like the body doesn’t compute the calories from liquid sugars as accurately as it does for sugars in foods.

On top of that, big sizes make the problems worse. To state the obvious, larger portions have more calories. If an 8-ounce soft drink provides 100 calories, then a 16-ounce drink provides 200, a 32-ounce drink provides 400 and a 64-ounce drink provides 800.

But big sizes also have other effects. They induce people to eat and drink more than they would if given smaller portions. Big sizes confuse people into underestimating the number of calories consumed.

Most people eat whatever size is in front of them – the “default,” in public health-speak – and are content with that amount. So a reasonable goal of public health intervention is to change the default drink to a smaller size. Hence: Bloomberg’s 16-ounce size cap.

From my nutritionist’s perspective, a 16-ounce soda is still generous. Just one contains the equivalent of 12 packets of sugar. Just one provides 10% of the daily calorie needs of someone who typically eats 2,000 calories a day. Just one contains the upper limit of sugar intake that health officials recommend for an entire day. Once you down a 16-ounce soda, it’s best to stop right there.

You may find this hard to believe, but the original Coca-Cola was 6.5 ounces, smaller than any size available today. In the 1950s, Coke advertised its 16-ounce bottle as large enough to serve three.

Times have changed. The sizes of foods and drinks have expanded, and so have waistlines. This is no coincidence. On the basis of calories alone, larger portions are all you need to explain why Americans are putting on pounds.

City officials concerned about the health of their citizens, as those in New York most definitely are, want to do everything they can to prevent obesity and the illnesses that go with it. Their rationale is humanitarian, but also fiscal. Poor health is expensive for both individuals and society. You don’t believe that excessive weight is an issue? Just ask the military.

We can thank Big Soda – Coca-Cola, Pepsi and their trade association, the American Beverage Association – for the contribution of big sodas to weight gain. Soda companies have spent fortunes to create demand, to make drinking large amounts seem normal, to market sodas as essential for health and happiness and, these days, to fight Bloomberg’s soda cap and take the city to court over it.

Soda companies may make things you like to drink, but they are not social service agencies. Their job is to get you to buy more soda to satisfy the financial demands of investors. They are about business. They are not about fun or happiness or personal choice – and they certainly are not about health.

The soda industry may profess to care more about your well-being these days, but it ultimately will not do anything to promote health if doing so harms sales.

So-called “nanny-state” measures – like bans on driving while drunk, smoking in public places and, now, selling absurdly large sugary drinks – help to level the playing field. Such measures are about giving everyone an equal opportunity to live a safer and healthier life.

At the moment, it is up to you to make healthier choices, but that’s not easy in the face of relentless soda marketing. Governments have a responsibility to provide healthier environments for their citizens.

Here are some additional actions New York City should take, if only it were allowed to.

Close the loopholes. The city does not have jurisdiction over sales of sodas in convenience stores and supermarkets. The state does. Gov. Cuomo denied Mayor Bloomberg’s request to extend the size cap to those stores, not on principle but because he hadn’t thought about it. He should, right now. Let’s keep all sugary drinks to 16 ounces or less.

Fix the price differential. A 7.5-ounce can of soda costs twice as much per ounce as a two-liter bottle, and you can’t buy just one; it comes in an 8-pack. Price determines sales. If a 16-ounce soda costs a dollar, a 32-ounce soda should cost two dollars.

Tax sodas. Most people wouldn’t dream of eating candy all day, but soda companies have made it seem normal to drink sodas from morning to night. Raising the price of sodas would discourage sales, especially among young people most susceptible to marketing efforts and most vulnerable to weight gain. A one-cent tax per ounce should do the trick and raise plenty of needed revenue besides.

Remove vending machines from schools. Yes, the Beverage Association only puts “better-for-you” drinks in school vending machines, but sugar-filled sports drinks are still liquid candy. And kids should not have to pay for water in schools.

Restrict marketing of sodas to children. Soda companies market extensively to children and adolescents, especially those in low-income neighborhoods. Just look at billboards, celebrity photos on soda cans and Pepsi’s $50 million dollar deal with Beyoncé. They should not be permitted to market to kids this way. We already have restrictions on cigarette and alcohol marketing to kids. It breaks no new ground to add sodas to the list.

Don’t let SNAP (food stamp) benefits be used for sodas. Bloomberg tried this, but the federal Department of Agriculture said no. There is absolutely no reason that taxpayer-subsidized food assistance for low-income people should go toward junk with no nutritional value. He should try again.

Show full calories on the front of containers. The current way calories are tallied, in a measure called “calories-per-serving,” is confusing because the servings are unrealistically small and people don’t do the math. Soda cans already give the full calories in tiny type on the Nutrition Facts label, but I want to see the full calories in big type on the front.

Actions like these will evoke ferocious opposition from the soda industry, and it will spare no expense to make sure such things never happen. We would surely hear more and more howls of “nanny-state” from those who insist Bloomberg has led us to the brink of a public health police state. Polls say that many New Yorkers oppose the 16-ounce cap and would oppose measures like this, too.

But I can’t tell whether the opposition comes from genuine concern about limits on personal choice or because soda companies have spent millions of dollars to protect their interests and gin up histrionic, misinformed opposition.

Come Tuesday, the 16-ounce soda is the new default size in New York City. While waiting for the court decision and for politics to play out, why not give it a chance? Maybe it will help you live a healthier and longer life.

Here’s my monthly (first Sunday) Food Matters column from the San Francisco Chronicle.The question (edited) came from a reader of this blog.

Q:You view New York City’s cap on any soda larger than 16 ounces as good for public health. I don’t care if sodas are bad for us. The question is “Whose choice is it?” And what role should the nanny state play in this issue?

A: Your question comes up at a time when the New York State Supreme Court is hearing arguments about whether New York City’s health department has the right to establish a limit on soda sizes.

As an advocate for public health, I think a soda cap makes sense. Sixteen ounces provides two full servings, about 50 grams of sugars, and 200 calories – 10 percent of daily calories for someone who consumes 2,000 calories a day.

That’s a generous amount. In the 1950s, Coca-Cola advertised this size as large enough to serve three people.

You may not care whether sodas are bad for health, but plenty of other people do. These include, among others, officials who must spend taxpayer dollars to care for the health of people with obesity-related chronic illnesses, employers dealing with a chronically ill workforce, the parents and teachers of overweight children, dentists who treat tooth decay, and a military desperate for recruits who can meet fitness standards.

Poor health is much more than an individual, personal problem. If you are ill, your illness has consequences for others.

That is where public health measures come in. The closest analogy is food fortification. You have to eat vitamins and iron with your bread and cereals whether you want to or not. You have to wear seat belts in a car and a helmet on a motorcycle. You can’t drive much over the speed limit or under the influence. You can’t smoke in public places.

Would you leave it up to individuals to do as they please in these instances regardless of the effects of their choices on themselves, other people and society? Haven’t these “nanny state” measures, as you call them, made life healthier and safer for everyone?

All the soda cap is designed to do is to make the default food choice the healthier choice. This isn’t about denial of choice. If you want more than 16 ounces, no government official is stopping you from ordering as many of those sizes as you like.

What troubles me about the freedom-to-choose, nanny-state argument is that it deflects attention from the real issue: the ferocious efforts of the soda industry to protect sales of its products at any monetary or social cost.

The lawsuit against the soda cap is a perfect example. It is funded by the American Beverage Association, the trade association for Coca-Cola, PepsiCo and other soft-drink companies, at what must be astronomical expense.

To confuse the public about corporate profits as a motive, the beverage association enlisted two distinguished civil rights groups – the NAACP and the Hispanic Federation – to file an amicus brief on behalf of its lawsuit.

Never mind that the obesity rate for the communities these groups represent is considerably higher than average in New York City, and that these neighborhoods would benefit most from the soda cap. The amicus brief argues that the soda cap discriminates against them.

The brief, however, neglects to mention that both amicus groups received large donations from soda companies and that the NAACP in particular has a long history of partnership with Coca-Cola.

Financial arrangements between soda companies and ostensibly independent groups demand scrutiny. National and local reporters – bless them – have done just that.

They report, among other connections, that one of the law firms working for Coca-Cola wrote the amicus brief, and that a former president of the Hispanic Federation just took a job with that company.

Last fall, the East Bay Express exposed how the soda industry exploited race issues to divide the electorate and defeat the Measure N soda tax initiative in Richmond. It revealed

that the beverage association not only paid for the successful “grassroots” campaign against Measure N but also encouraged views of the soda tax as racist.

Driven by this experience, the soda industry is repeating this tactic in New York City.

Is a cap on soda sizes discriminatory against groups working for civil rights? Not a chance.

Public health measures are about alleviating health disparities and giving everyone equal access to healthy diets and lifestyles. This makes public health – and initiatives like the soda cap – broadly inclusive and democratic.

If anything is undemocratic and elitist, it is suing New York City over the soda cap.

In funding this lawsuit, the soda industry has made it clear that it will go to any length to protect its profits, even if it means discrediting the groups that would most benefit from this rather benign public health initiative.